“I’m
addicted to painkillers,” J., a thickset construction worker, told me on a
recent afternoon in the emergency room, his wife at his side.

Two years
before, after months of pain, stiffness and swelling in his hands and neck, his
primary physician had diagnosed rheumatoid arthritis and had prescribed three
medications: two to slow the disease and one, oxycodone, for pain.

Bolstered
by the painkiller, J. had felt more limber and energetic than he had in years.
“I could finally keep up with the other guys,” he told me. He worked harder,
and his pain worsened. His primary physician increased the oxycodone dose.

Soon, J.
was looking forward more to the buzz than to the relief the pills brought. He
went to see two other physicians who, unaware that he was double-dipping,
prescribed similar medications. When a co-worker offered to sell him
painkillers directly, J.’s use spiraled out of control.

By the time
I saw him, he was taking dozens of pills a day, often crushing and snorting
them to speed the onset of his high. With remarkable candor, he described how
the drugs had marred every facet of his life — from days of missed work to
increasing debt, deteriorating health and marital strain.

But when I
listed the treatment options that might help, J. shook his head, looked from me
to his wife, and got up. “I’m all set,” he said, holding up his hands.

She’d found
him twice in the past week slumped on the bathroom floor, impossible to arouse.
Though she’d called 911, both times the hospital released J. within hours after
he came to and insisted the overdose was accidental. “I just know I’m going to
come home one day to find him dead,” she said.

She had
good reason to worry. Prescription drug abuse is America’s fastest-growing drug
problem. Every 19 minutes, someone dies from a prescription drug overdose in
the United States, triple the rate in 1990. And according to the Centers for
Disease Control and Prevention, prescription painkillers (like oxycodone) are
largely to blame. More people die from ingesting these drugs than from cocaine
and heroin combined. Yet while I shared her concern, there was little I could
do to force J. into treatment.

My hospital
happens to be in Rhode Island, one of about a dozen states where compulsory treatment
for someone like J. (that is, someone not under the purview of the criminal
justice system) does not exist. Had J. been a resident of nearby Massachusetts
— or from one of more than 20 other states that permit involuntary addiction
treatment — I would have suggested his wife petition a judge to force him into
care. Had we met in any of a dozen states, I could have hospitalized J. myself
— against his will and for up to several days.

The
requirements for involuntary substance treatment vary widely across the nation,
from posing a serious danger to oneself, others or property, to impaired
decision-making or even something as vague as losing control of oneself. States
approach compulsory treatment for mental illness with far greater uniformity.
All allow it, and almost all restrict it to instances in which a patient poses
an immediate danger to himself or another.

This common
standard stems from a series of federal court cases that set procedural and
substantive requirements for mental health commitments. But involuntary
commitment for addiction treatment, while certainly not new, has received
considerably less judicial attention.

In a 1962
case, Robinson v. California, the Supreme Court held that while conviction
solely for drug addiction was unconstitutional, “a state might establish a
program of compulsory treatment for those addicted to narcotics.” Many did,
others didn’t. The high court has yet to revisit the issue.

Another
complicating factor is society’s disagreement about what addiction really is: a
disease, a moral failing or something in between. Many (often patients
themselves) see drug abuse as purely a choice. Under this view, justifying the
lost autonomy and expense to taxpayers that accompany mandated treatment
becomes a hard sell.

Yet a large
and ever-growing body of research paints a far more complicated picture of
addiction.

The
cognitive concepts that we typically associate with “willpower” — motivation,
resolve and an ability to delay gratification, resist impulses and consider and
choose among alternatives — arise from distinct neural pathways in the brain.
The characteristic elements of drug abuse — craving, intoxication, dependency
and withdrawal — correspond with disruptions in these circuits. A host of
genetic or environmental factors serve to reinforce or mitigate these effects.
These data underscore the powerful ways in which addiction constrains one’s
ability to resist.

The spotty
existence of commitment laws for addiction has created something odd in
medicine: a landscape where the standard of care differs dramatically from one
place to the next. But change seems to be afoot. In March, Ohio passed a law
authorizing substance-related commitments. Pennsylvania is considering a similar bill.

In July,
Massachusetts extended its maximum period of addiction commitment from 30 days
to 90 days, a move driven by the state’s growing opioid abuse epidemic. In the
same month, however, California terminated its commitment program for drug
abuse.

These
shifts come at a time when private insurers increasingly refuse to cover even
brief inpatient stays for treatment of opioid abuse and as states grapple with
dwindling resources. Still, while short periods of involuntary custody make
intuitive sense — to provide protection until the effects of intoxication or
withdrawal subside — surprisingly little evidence exists to suggest that a
longer period of commitment will lead to abstinence or prevent the behavior
that justified commitment in the first place. Science must guide the crafting
of these laws, but for now the empirical jury is decidedly out.

As I
watched the color drain from J.’s wife’s face, I decided to speak with him
again. Short of forcing him to stay, I knew what she wanted was for me to change
J.’s mind.

He stood
near the exit, arms folded, coat zipped. I waited next to him and for several
moments said nothing. Then I wondered aloud whether he feared the physical pain
that existed apart from his addiction. Without looking at me, he nodded.

“What if we
can find a way to treat your pain and also bring an end to the hurt this is
causing you and your family?” I asked. “Perhaps together we can help you get
your life back.”

J. paused
to consider my offer. For an instant, his face softened.

Then, just
as quickly, he jerked his head and was gone. His wife followed him out, in
tears.